The Introduction of Hospitals
Initially, almshouses or poorhouses were the main form of hospital care. These "hospitals" provided care for individuals who did not "fit into the traditional" sense of family care. In other words, they treated destitute individuals who had no other way to turn and housed mental patients who were ostracized from society. Eventually, Hospitals were created and existed alongside almshouses. Hospitals popularized as specialization increased in the medical field and as the number and type of patients, besides the traditionally poor individuals who came to almshouses, increased.
Although, making hospitals the main venue for care was a long process. In order to sustain hospitals, the number of medical professionals needed to increase. Nurses were the first to do so as women who wished to enter the field began training schools. Surgeons were the next group to increase. Knowledge about different surgical procedures increased and tools for surgery, such as antiseptis, were discovered. This allowed surgeons to broaden their practice to encompass more illnesses and let them work more often. At first, surgeons continued to work at patient's homes, but soon there was a need for more space, availability of more tools, etc. Eventually, hospitals became the main venue for surgeries.
Shifting Focus & It's Effects
These changes eventually allowed hospitals to be used for entirely new reasons. Previously, hospitals treated chronic illnesses and housed patients for long periods of time. Now, hospital personnel targeted more acute illnesses that allowed for quick discharges. In the end, there was a shift from moralistic to medical objectives, as hospital personnel focus changed from treating patients for moral, even religious, means to those that best fit the present medical needs.
The shift in hospital priority greatly changed other aspects of hospitals. Hospitals began to serve richer patients as demand for more expensive services (like surgeries) grew. These patients had high expectations for care and many required private rooms. Soon, private quarters replaced customary community patient wards. The reflects the general change that occurred-- instead of serving poor patients, which had been the main goals of hospitals until this time, hospitals were now serving more and more rich patients.
The relationship between patient and physician changed. In almshouses, patients had oftentimes assisted in cleaning and minor treatment procedures. In general hospitals, all services were "taken over completely be employees of the institutions." Thus, there was now a clear distinction between patient and caregiver.
The last major change that occurred was a significant increase in hospital costs. Construction and operation costs went up dramatically. But, instead of depending on donations or charity money as hospitals had in the past, hospitals could now depend on payments from patients. Consequently, medical professions gained power over the hospital as they brought in more money and trustees lost their power.
Physician "Classes" Pursued
There was a specific "class" system in hospitals. The hospital medical staff was arranged into four groups:
- consulting staff, composed of older and distinguished physicians,
- visiting or attending staff, active physicians who supervised treatment;
- a resident or house staff of young doctors in training;
- and, a dispensary staff that saw outpatients.
Doctors that worked in hospitals were not paid. However, obtaining a job in a hospital was now very important because it helped physicians establish themselves as professionals. Thus, the following system was conceived: all the house physicians gave services in exchange room and board, dispensary staff gave services in hopes of becoming visiting physician, and visiting physicians gave services for access to surgical facilities.
Fraternity Systems
Physicians became obsessed with finding new ways to establish themselves. Although the number of hospital jobs were increasing at a steady rate (more and more hospitals were being built), many young physicians were unable to obtain hospital jobs. When excluded, these young physicians looked for different ways to gain professional prestige.
A new fraternity or ranking system of sorts came to be. Medical professions would work to make connections, etc. in hopes of finding a position in a hospital. Medical societies offered social advantages for their members. They slowly gained influence over hospital employment. By the early 20th century, many organizations, such as the AMA, required hospitals to only employ physicians who were members of their organization. Medical societies enjoyed incredible power at this time; through this social power, they were even able to exclude minorities, such as African Americans, from obtaining hospital jobs.
Physician-Controlled Hospitals
In 1890, perhaps angered by the politics that controlled hospital employment, many physicians began creating their own for-profit hospitals. These hospitals were mostly surgical centers and had no ties to medical schools. They relied only on fees paid by patients. Physicians at these hospitals treated patients from all backgrounds: poor patients were oftentimes treated for teaching purposes and rich patients were often treated to ensure a steady flow of income. This environment allowed for a great teaching opportunity -- physicians came across all types of patients.
Ending Details
There are several other details about the history of hospitals in this chapter. Yet, I find the last couple pages the most interesting. Here, Starr talks about how the source of authority over hospitals changed throughout American history. As stated earlier in this post, hospitals began as almhouses headed by trustees. Trustees were the sole source of authority because they could bring in the charity funds needed to keep the early hospitals going. These hospitals mostly treated poor patients and housed mental patients; neither groups could pay for these services. At the turn of the century, there was a surge in medical knowledge that allowed for medical specialization. Medical professionals were now able to offer a number of specialty services to wealthy patients. Medical professionals now required standardized venues for their services and patients required private, possibly elaborate, quarters to stay in during the services and recovery. Eventually, medical professionals were able to take control of hospitals because the fees they brought in were needed to run hospitals. But, the major change came next. As hospitals' infrastructure and necessities increased, it became necessary to bring in other individuals who could effectively run these large institutions. Thus, administrators were brought in to run hospitals. To this day, three parties have authority over hospitals: trustees, physicians, and administrators.As Starr states, hospitals are one of the few institutions that were able to elude the bureaucratic concept of having one, single authority figure.
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